Tropical Health Matters

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

• In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
• Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
• Funding for malaria has remained relatively stable since 2010
• To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..

Anthony Chisada, Paul Matsvimbo, Munekayi Padingani, Tsitsi Siwela of Jhpiego,the USAID ZAPIM Project, Harare, Zimbabwe,  and the Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe presented their experiences using death audits at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings follow.

Nearly 50% of the Zimbabwean population is at risk for malaria. Total numbers of malaria related deaths have remained almost constant over the past 5 years. The National Malaria Control Program’s National Malaria Strategic Plan aims to reduce malaria-related deaths by 90% from 2015 levels (462 deaths) by 2020.

To improve severe malaria care and reduce mortality, NMCP documents and investigates all malaria deaths to ascertain the cause of the death and understand if and how it was avoidable. Malaria death audit meetings are held quarterly with health facility staff using a standard death investigation form and case management notes and form a learning platform to look at qualitative and quantitative data related to the deaths.

The audits also examine the quality of care offered as per treatment guidelines and seek to identify ways to prevent future malaria deaths based on omissions and errors in presented cases.

This review examines the findings from death audit meetings facilitated by the PMI-funded Zimbabwe Assistance Program in Malaria project in the Zimbabwean provinces of Mashonaland Central, Mashonaland East and Matabeleland North. Six death audit meetings were conducted over an 18-month period, resulting in a total of 80 deaths audited. The audited deaths were purposely sampled for the potential learning value they offered and to diversify lessons learned.

According to audit reports, the main contributing factors to malaria deaths included: delayed presentation by patients, lack of comprehensive assessment and documentation of cases, inadequate care for patients with reduced level of consciousness and shock, inadequate follow-up of patient progress, lack of supportive investigations, and lack of access to renal replacement therapy/dialysis and blood transfusion.

Most deaths in age groups: under 5s(30%) and over 15(44%). Children are at risk of dying from malaria because of underdeveloped immunity, women taking children to gardens at night, delayed presentation  since mothers are busy. Problem most pronounced in UMP. People over 15 years also at risk of dying: Suggestive of exposure as they indulge in outdoor activities without any protection from mosquito bites.

Death audits reapportion delays (3rd delay increased from 8% to 28%). First delay remains the major contributory factor- need for strengthening SBCC efforts. Malaria death audit meetings enhances the usefulness of the malaria death surveillance system and provides an opportunity for identification and discussion of health system challenges. Some challenges identified are rectifiable thus mitigating deaths. These enable holistic patient care: Identification and management of co-morbidities is critical. Findings contributed to justification of introduction malaria clinical mentorship for improving QoC.

The introduction of malaria death audit meetings has added an active, learning platform to complement the use of the malaria death investigation form and also served as a useful learning tool within Zimbabwe’s clinical mentorship program. Regular malaria death audit meetings are potentially useful in improving malaria care and reducing malaria related deaths.

Jasmine Chadewa, Chonge Kitojo, Goodluck Tesha, Naomi Kaspar, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, George Greer, Abdallah Lusasi, and Sigsbert Mkude of the USAID Boresha Afya Project, the US President’s Malaria Initiative, the National Malaria Control Program, and the Community Development, Gender, Elderly and Children (Tanzanian Ministry of Health) shared how malaria data quality could be improved at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Below are their findings.

Tanzania has a high malaria burden (see Figure 1) and is facing an increased demand for health services. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed the Malaria Service and Data Quality Improvement (MSDQI) checklist to guide supportive supervision teams in evaluating the quality of malaria case management (MCM) services at facility level. MSDQI helps with the collection, monitoring, and evaluation of facility-based malaria performance indicators at all levels of service delivery that provide timely, accurate information and data for decision-making at district, regional, and national levels.

USAID Boresha Afya conducted MSDQI assessments in 1,222 health facilities in the Lake and Western zones in outpatient departments (OPDs) and during antenatal care (ANC). The program disseminates malaria and ANC guidelines, tablets, job aids, and standard operating procedures. It also continues to facilitate supportive supervision and mentorship through the MSDQI tool to build providers’ capacity in identified areas.

Among the challenges reported, Supervisors need to be trained in more than one module to reduce cost. There is turnover of MSDQI supervisors. Cases that come back positive for diseases other than malaria are not investigated further. The use of Android smartphones sometimes interfered with data collection and the reporting system. • Regions/districts depend on donor support to implement MSDQI activities.

In conclusion, effective implementation of the MSDQI tool requires regions, districts, and facilities to be well informed and given clear instruction so they can form supportive supervision teams. This should be done by:

• Orienting teams on roles and responsibilities
• Training teams on relevant competencies, resource allocation, and tablet

use for data collection

The team learned that MCM improved in OPDs and during ANC as a result of the MSDQI assessment. Improved access to quality MCM (diagnosis) nationwide. Frequency of malaria testing increased during the first ANC contact. Testing increased from 87% in April–June 2017 to 96% April–June 2018, a 9% change (see Figure 3). Second doses of intermittent preventive treatment of malaria in pregnancy (IPTp2) coverage increased by 15% on average in Boresha Afya-supported regions between October 2016 and June 2018 (see Figure 4).

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.

Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).

As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.

Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health

Barriers for Caregivers are seen in the attached table. Barriers were faced by both care seekers and those who did not seek care, but were more common among non-seekers.

Three tables follow that show perceptions of public sector providers, private providers and community health workers. There were positive and negative perceptions of each group of providers.

Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory

General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system

Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Goodluck Tesha, Zahra Mkomwa, Jasmine Chadewa, Lusekelo Njoge, Abdallah Lusasi, Dunstan Bishanga, Chonge Kitojo, Erik Reaves, George Greer of the USAID Boresha Afya Project, the Tanzanian Ministry of Health, and the US President’s Malaria Initiative shared experiences on the role of malaria case management in pre-elimination efforts at the 2018 Annual Meeting of the American Society of Tropical medicine and Hygiene. Their results are seen below.

The 5-year USAID Boresha Afya project works in 1,817 facilities in the seven regions of the Lake/Western Zone, where malaria prevalence is high. Since 2016, Boresha Afya has collaborated with the National Malaria Control Program to support the goal of reducing the malaria case fatality rate to below 1% by 2020 by:

• Promoting universal access to early diagnosis and prompt treatment
• Providing preventive therapies to vulnerable groups

In the last 15 years, malaria transmission has been cut in half, dropping from about 33% to less than 7.5%. Over the last three malaria indicator surveys, the number of regions with extremely low malaria prevalence (<1%) increased from one (2008) to seven (2016). The percentage of the population living in low-transmission areas (<10% prevalence) increased from 31% in 2000 to 49% in 2015.

The intervention trained providers on quality testing using malaria rapid diagnostic tests (mRDTs). Training focused on conducting quality malaria microscopy examinations.

In addition, the team stratified malaria burden using GIS mapping and introduced malaria service and data quality improvement through a malaria dashboard. Community outreach programs were formed in remote areas.

Due to mRDT availability, more suspected malaria cases are tested before malaria treatment is administered. Per national guidelines, all pregnant women should be tested for malaria on their first visit to the clinic. All project regions have met or exceeded the national 80% testing rate target (see Figure 5).

In conclusion, to move toward malaria elimination, Boresha Afya will focus on ensuring more suspected cases are tested at facility level. Prompt treatment positive cases will then follow. Performing more community outreach should increase access to malaria case management in remote areas. Using GIS mapping will rapidly target services.

This poster is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Jhpiego and do not necessarily reflect the views of USAID or the United States Government.

Thomson Ngabirano, Espilidon Tumukurate, Innocent Atukunda, Emily Katarikawe, Jimmy Opigo, Martin Muhire, Emily Goodwin, Sam Gudoi, Kassahun Belay, Peter Thomas, James Tibenderana have been working with the following partners in Uganda to improve malaria case management: Jhpiego, United States Agency for International Development’s (USAID) Malaria Action Program for Districts (MAPD) Project, Uganda National Malaria Control Program, Ministry of Health, University Research Co., the USAID ASSIST Project, Malaria Consortium, US President’s Malaria Initiative, and the US Centers for Disease Control and Prevention, Uganda. Their work, seen below, was presented at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria has a 19 percent parasite prevalence in Uganda and is a leading cause of morbidity and mortality in Uganda and in 2014 was responsible for:

• 30-50 percent of outpatient visits
• 15-20 percent of hospital admissions
• 20 percent of inpatient deaths.[1]

In an effort to reduce its malaria burden, in 2016 the Ministry of Health in Uganda incorporated a number of World Health Organization recommendations into its National Malaria Policy Guidelines. The main elements in these guidelines implemented by health workers were:

• testing all suspected malaria cases with malaria rapid diagnostic tests (mRDT) or microscopy before treatment
• using artemisinin-based combination therapy (ACT) to treat only positive malaria cases
• providing at least three doses of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP).

However, a number of challenges for malaria service delivery were encountered during

implementation, including incomplete, inaccurate, and inconsistent malaria records and reports; health workers not adhering to the malaria test, treat, and track policy; and malaria causing high caseloads at outpatient and inpatient service points.

To overcome these issues, and in particular to improve adherence to the malaria test, treat and track policy and strengthen the quality of data collection and recording, USAID’s Malaria Action Program for Districts (MAPD) implemented a collaborative quality improvement approach (CQI).

A CQI approach was introduced to MAPD in November 2017 and implemented using both qualitative and quantitative methods. These included reviewing malaria indicators on the District Health Information System, identifying 10 high-volume facilities across MAPD’s five operational regions with poor malaria indicators (see Figure 1), holding entry meetings with the district health teams, conducting collaborative data reviews and problem analysis with health facility staff, and presenting the results of data reviews to health facility staff to identify inaccurate reporting and non-compliance with the test, treat and track policy. Interventions also included working with health facility staff to identify potential solutions and interventions, implementing agreed interventions and reviewing indicators, monitoring progress using documentation journals, holding learning sessions led by a CQI coach, agreeing on new actions.

Malaria data indicators reviewed include accuracy and completeness of cases in lab register and OPD, number of fever cases tested for malaria using mRDT or microscopy, number of malaria-negative cases treated with ACTs, number of malaria-positive cases treated with ACTs, and number of pregnant women receiving three or more doses of IPTp-SP.

In a sample of 300 cases from a June 2018 lab register, taken eight months after the CQI approach was introduced, all 300 (100 percent) were recorded in the respective OPD register. This represents a 108 percent increase from when an equivalent sample was first reviewed in November 2017. In a sample of 300 patients that were treated using ACTs in June 2018, all patients were tested for malaria using mRDTs or microscopy and no patients were treated that had tested negative. This represents an 89 percent decrease from November 2017 when 27 (nine percent) malaria-negative cases were incorrectly treated using ACTs.

Of the total 264 expectant mothers (who were 28 weeks pregnant and above) that attended ANC visits in July 2018, 142 (54 percent) received three or more doses of IPTp-SP. This is a marked increase on the 43 percent of pregnant women who received three or more doses in November 2017.

Feedback from discussions with health workers in facility meetings and regional learning sessions showed that health teams now accept that there is a need for accurate and complete data and understand the importance of adhering to the National Malaria Policy Guidelines. In conclusion … The CQI approach was found to promote accurate data collection and improve adherence to the malaria test, treat, and track policy among health workers at 10 health facilities in five regions of Uganda.

[1] Reference: Uganda Bureau of Statistics (UBOS) and ICF International. Uganda Malaria Indicator Survey 2014-15. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF International; 2015. Available at https://dhsprogram.com/pubs/pdf/mis21/mis21.pdf

MAPD is a project (running from 2016-2021), funded by the US President’s Malaria Initiative, USAID, UK aid, and the government of Uganda, which aims to improve the health status of the Ugandan population by reducing malaria-related morbidity and mortality among children and pregnant women. This poster was made possible by the support of the American and British People through the United States Agency for International Development and UK aid from the UK government. The contents of this poster are the sole responsibility of USAID Malaria Action Program for Districts and do not necessarily reflect the views of USAID or the United States Government and do not necessarily reflect the UK government’s official policies. For more information, please contact; 1. Dr Thomson Ngabirano, Malaria in Pregnancy Specialist Thomson.Ngabirano@Jhpiego.org 2. Dr Sam Siduda Gudoi, Chief of Party s.gudoi@malariaconsortium.org

Maya Tholandi, Lolade Oseni, Anne McKenna, Herbert Onuoha, Solofo Razakamiadana, Elsa Nhantumbo, Alain Mikato, Elaine Roman of Jhpiego and the Johns Hopkins Bloomberg School of Public Health shared important Baseline Readiness Assessment Findings from Democratic Republic of the Congo, Mozambique, Madagascar, and Nigeria from the UNITAID-supported TIPTOP on Intermittent Preventive Treatment of malaria in pregnancy at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) is unacceptably low in most of sub-Saharan Africa. A Jhpiego-led consortium is implementing the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, which supports community distribution of quality-assured sulfadoxine-pyrimethamine (SP).

TIPTOP aims to increase IPTp3 coverage from 19% to 50% of eligible pregnant women in project areas in Democratic Republic of the Congo (DRC), Madagascar, Mozambique, and Nigeria. The project, operating from 2017 to 2022, provides quality-assured SP, promotes community awareness, and supports supervision and coordination efforts between health facilities and community health workers (CHWs).

In 2017, a baseline assessment examined facility readiness for malaria in pregnancy management, antenatal care (ANC) provider knowledge, CHW characteristics and health facility linkages, and health management information system (HMIS) quality. TIPTOP assessed 140 facilities and interviewed 175 ANC providers and 67 CHW supervisors.

At project startup, the teams examined SP stock, ANC providers and CHW availability. SP Stock assessment showed a disparate stock maintenance processes and stock-out next steps indicate lack of a coherent and consistent approach to stock monitoring. In half of all cases, caregivers offer a prescription when stock is not available in the facility, with smaller numbers requesting.

Among ANC providers, 80% on average correctly reported that at least three doses of IPTp are recommended. On average, 64% correctly responded that SP should be initiated in the second trimester. Out of the 170 providers interviewed across countries, only five knew all the key signs of suspected malaria.

A low numbers of CHWs in some districts may limit their reach and capacity. Inadequate CHW education and ANC familiarity may diminish training effectiveness. In particular, low numbers of female CHWs may decrease community acceptance and pregnant women’s acceptability of receiving IPTp from CHWs.

Data Quality and Availability from the routine services would affect monitoring of interventions. Over-reporting of ANC contacts and IPTp service provision is a data quality challenge. The HMISs in Nigeria and Mozambique record IPTp3 provision, but only at the local level. Supervising facilities do not always review data before HMIS entry for accuracy.

Concerning Monitoring and Evaluation System Components, Mozambique’s HMIS is the strongest of the four countries in terms of linking to the national system, current tools and reporting forms available in the facilities, and providers reporting an understanding of indicators and data reporting processes. Nigerian facilities had limited knowledge of indicators and their definitions, despite this information being available in Federal Ministry of Health-provided registers. Madagascar struggled with indicator definitions and data management processes. DRC faced the most challenges: Tools and reporting forms were not available in health facilities, and there were limited monitoring and evaluation structures and processes.

In Conclusion, Results from the baseline assessment are Informing efforts to improve data quality and CHW facility data flow in TIPTOP implementation areas. There is need to strengthen ANC provider knowledge through TIPTOP-supported trainings. One also needs to address CHW variation by country and support health facilities to monitor their SP stock. These findings are being shared with ministries of health and key stakeholders to inform malaria implementation and data quality efforts.

Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Mathurin Dodo, Danielle Burke, William Brieger, and Gladys Tetteh of Jhpiego and the Improving Malaria Care Project (USAID) in Burkina Faso presented a poster on helping hospitals develop a malaria response plan. Their findings are shared below.

In Burkina Faso Malaria cases peak from June-September (rainy season), exceeding hospital capacity and causing high number of deaths, especially in children under 5 years of age. The Improving Malaria Care Project, funded by USAID/President’s Malaria Initiative, provided support to National Malaria Control Program to develop and implement malaria preparedness and response plans in all 11 regional hospitals

The Objectives of this effort aimed to describe development and implementation of malaria preparedness and response plan. From this the project planned to share lessons learned and challenges Malaria Preparedness and Response Plan Development and Implementation Process is seen in the attached chart.

In preparation of hospital staff for planning, the training reached Nurses and midwives were largest groups of trained providers at 52% and 30%, respectively. Providers were selected by hospital management team from pediatric maternity and emergency units.

Severe Malaria Cases Trend Regional Hospital in Burkina Faso is seen in the attached graph. In a second graph, Malaria Case Fatality Rate Trend at Regional Hospitals in Burkina Faso is shown. Even though there were more cases of severe malaria in 2017, Malaria case fatality rate decreased after implementing malaria response plan.

Challenges faced by the hospitals included Lack of funding for response plan activities, which were not included in the routine hospital work plan. Also there was a Lack of beds in some hospital rooms, especially in pediatric unit. Timing of clients coming to hospital posed a challenge as many do not come early and sometimes come when only complications start.

Lessons learned from the intervention include the fact that On-the-job training is opportunity to improve providers’ skills. Response plans must consider that providers’ refreshment, and securing blood and other commodities may improve severe malaria case management. Monthly data collection and analysis may highlight progress in malaria planning through case management and orient decision-making. Follow-up visits strengthened provider engagement on severe malaria case Management

In Conclusion, Response plans may provide a way to reduce malaria mortality. Each hospital should consider incorporating response plan into its annual work plan

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.